While discussions about the social determinants of health are featuring more prominently in the nation’s current health policy conversation, many organizations, like the Camden Coalition, have been working for years to understand and address this intersection. In 2016, we created the National Center for Complex Health and Social Needs as a way to build a field that addresses what we have come to call complex care. The field has yet to discover the full set of solutions that bridges the gaps between medicine, behavioral health, public health, and social services to guarantee better health and well-being, but recent discussions about “social determinants” provide new pathways of hope and inquiry. In the spirit of reflection and continuous learning, we thought it was timely to share the story of the Camden Coalition’s 15-plus years developing a care model that is centered around both health and social complexity. We hope it encourages others to start, continue, persist, or expand this work.

In this four-part series, we describe the phases of our work as we addressed challenges and tested new solutions.

• Part 1 describes our roots as coalition builders in Camden City and early work in care provision and management for patients with complex health and social needs (2007-2011).
• Part 2 details how we refined our ability to identify high-needs patients through data (“healthcare hotspotting”) and adapted our care model to link patients back to permanent primary care or specialty providers (2012-2013).
• Part 3 explains the significant changes we made to our care management model to better address and meet social needs, and our efforts to share what we were learning with the field (2014-2017).
• Part 4 shares our vision for building complex care ecosystems in the Camden region and nationwide (2018 and beyond).

Read the full piece in a brief or on Medium.